Health care doesn't keep people healthy -- even in Canada

By
Ezra Klein

File this one under "health care doesn't work nearly as well as we'd like to believe." A group of researchers followed almost 15,000 initially healthy Canadians for more than 10 years to see whether universal access to health care meant that the rich and the poor were equally likely to stay healthy. The answer? Not even close.

The researchers ran the data two ways: High-income patients vs. low-income patients, and highly educated patients vs. less educated patients. Over the course of the study, the high-income patients were only 35 percent as likely to die as the low-income patients, and the highly educated patients only 26 percent as likely to die as the low-income patients. And the problem wasn't that the low-income and low-education patients were hanging back from the health-care system. Because they were getting sick while their richer and better educated counterparts weren't, they actually used considerable more in health-care services.

The problem, the researchers say, is that the medical system just isn't that good at keeping people from dying. "Health care services use by itself had little explanatory effect on the income-mortality association (4.3 percent) and no explanatory effect on the education-mortality association," they conclude.

You don't want to over-interpret this data. It's possible that in the absence of insurance, the gap would be much wider. Indeed, there's good evidence suggesting that's true. Nevertheless, this should make us very skeptical about a world in which we're spending almost one out of every five dollars on health-care services. Universal insurance is crucial both for certain forms of health care and for economic security. But as I've argued before, it's probably not the best way to make people healthier. Rather, the best way to make people healthier would be to get health-care costs under control so there's more money in the budget for things like early-childhood education and efforts to strip lead out of walls, both of which seem to have very large impacts on health even though we don't think of them as health-care expenditures.

As I have said before, if health care reform was really about health, it would have mandated a healthy diet and exercise, not insurance.

If lack of insurance results in the death of thousands each year, the failure to mandate good health habits probably results in hundreds of thousands of deaths annually. Of course, I would never advocate that sort of expansion of the nanny state, I only suggest that it would likely achieve better results, and for far less money.

"Nevertheless, this should make us very skeptical about a world in which we're spending almost one out of every five dollars on health-care services."

Quit subsidizing and paying for insurance, and spending will go down. One could plausibly argue that if no one had health insurance, fewer people would die (i.e. people would be on the hook for their bills, and at least some would choose healthier lifestyles in response).

As one who benefits from Canadian Health care I can tell you that it's a great safety net. We don't really worry about health care up here. In fact, until we need it, few of us rarely even think about it.

That must count for adding to our quality of life at least right?

That said, it is not an aggressively proactive system, and of course it should be.

The first thing to say is that just because the Canadian health care system is doing something poorly, isn't an indictment of universal health care policy. Secondly, there are quite a number of plausible explanations as to what the Canadian health care system is doing wrong, with proposed solutions to match. They are not inherent to the system by which health care is delivered to patients (unlike for-profit insurance companies who have a disincentive to pay for care).

Foremost amongst criticisms of both the US and Canadian healthcare systems is that they do a terrible job of providing comprehensive or preventative care such that people with chronic long term problems such as diabetes never devolve to the point at which they require serious and immediate health care. Its cases like these (i posit) where things like income and education gap matter most. Doctors and allied health professionals can only do so much to assist, there is a lot of discretion which remains up to patients as to what they are going to do to manage their health.

That there is a disparity between rich and poor in terms of health care outcomes doesn't mean that universal health care isn't improving the lives of Canadians. It's just not (yet?) a social equalizer.

Really though, this study just shows why we need better information on methods that actually help people.

The White House has tried to implement computer based records so doctors and researchers can compare information and find better solutions to help people. Unfortunately the implementation (last time I checked) has been slow.

I think the primary differences between universal healthcare favored by most countries and the US system which is geared towards profit are the following:

1. People are discouraged from seeking preventative care both because of the cost (with or without insurance) and the increase in their premiums for the sin of making a claim.

2. The insurance companies, not the doctor or the patient, decides what medicine they can go to, what doctors they can see, and what hospitals they can receive treatment from. You can't even choose your own dentist.

3. Under universal healthcare, a citizens taxes pay for their coverage and those taxes don't fluctuate depending on the care received. In the United States, citizens must pay a premium over and above their taxes - which are cost-prohibitive without employer/ govt subsidies. Once they do receive care, the premiums will drastically increase to discourage further claims.

4. Getting cancer in Canada costs the patient almost nothing compared to the United States, where treatment and medicine is 3-6 times more expensive than any other country in the world. The leading cause of bankruptcy in America are healthcare costs.

5. The bureaucracy and paperwork demanded by the US system adds an enormous and unnecessary expense. Those providing treatment often struggle to get paid and less than what they would charge if the patient paid in cash on the spot. To add insult to injury (apologies for the pun), federal law requires that hospitals provide emergency treatment to those without insurance and/ or the ability to pay, which leaves the burden on the hospital.

For a country that claims to despise taxes, it seems extraordinary to me that it's people are willing to pay thousands of dollars extra every year whether they are healthy or not, and force businesses to share a burden that often amounts to an extra $10,000 per employee.

And the worst part of it all? Even if you can afford it, the US can't even boast that it provides the best healthcare in the world.

Apologies for the long rant, but I challenge and request that anyone prove me wrong, on ANY of these points.

kiweagle is right on all counts . The Canadian system may need some reforms or tweaks but it has the basic frameowork and people are not going bankrupt because of medical bills. The cost of drugs , the insane amount of paperwork ( or computer work , same thing ) the hundreds of employees at Insurance Co's dedicated to refusing and rationing care in order to maximise their profits , these are the causes of increased cost .

I was disappointed at the low and misguided level of analysis of this article. At least it ends on a note of evidence-based common sense as to what REALLY keeps people healthy (i.e. childhood eduction for example).

@ justin84: There is a large body of evidence that shows that, unlike what people think and may intuitively hold for true, population health does not depend on exercise, diet and healthy lifestyles. Rather, there are broader determinants that are largely outside most people's control that actually shape their abilities to even CHOOSE a healthy lifestyle. The notion that people are encouraged to lead very careless lives - where they knowingly choose to get morbidly obese, chronic diabetes or heart disease, just because they have a subsidized health care system - is simply not verified by research at best, and actually quite prospesterous at worst....

"There is a large body of evidence that shows that, unlike what people think and may intuitively hold for true, population health does not depend on exercise, diet and healthy lifestyles."

I'm anti-nanny state, so that works for me. I'm not going to take your word for it though. Do you have even a single link to a representative example of this large body of evidence?

Why does the government/health care profession keep recommending a certain diet, exercise, and the cessation of smoking if it doesn't matter? Just for kicks? Shouldn't we just smoke, eat whatever we want, and sit on our couches if going to the gym and eating right doesn't do anything? Was Morgan Spurlock's Super Size Me documentary a fraud?

"Rather, there are broader determinants that are largely outside most people's control that actually shape their abilities to even CHOOSE a healthy lifestyle."

Baloney. Nearly everyone could choose a healthy lifestyle if they wanted to.

"The notion that people are encouraged to lead very careless lives - where they knowingly choose to get morbidly obese, chronic diabetes or heart disease, just because they have a subsidized health care system - is simply not verified by research at best, and actually quite prospesterous at worst"

Some people will respond to incentives, regardless if you - or even most people - do not. Some people would surely cut back on their sugar intake if they were faced with all of the health costs of diabetes, for example.

In one sense I agree with your title: currently our health care 'system' treats people the same way that we repair cars following an accident: fix 'em up as best we can and put 'em back on the road. But at least we know enough to invest in accident prevention. Why not disease prevention? That's where the money is.

We should consider defining the purpose of health care not as 'fixing' people but as maximizing wellness. We need to stop emphasizing treating health 'failures' and put money upstream in wellness and prevention.

We should also consider changing the way health insurance companies and health care workers are reimbursed for health care services: from a system that sucks money out of health care to corporate profits, a system that pays for health care the same way machinists and workers in the sex trade are paid - piece work and incentives, pay for performance - to a salary or capitation system than rewards prevention. This would re-focus resources on meeting patient needs and treating the causes of costs - economic inequality, lack of early childhood/family economic and educational support, for instance - rather than health failures and profits.

Health care is obviously better for treating illness than no health care, and access to preventative treatment and advice is obviously better at preventing poor health than is a lack of access to that treatment and information.

Mortality rates and "healthiness" are not the same thing. If access to health care had no utility toward health at all, then NONE of us would bother to see physicians, or to carry insurance to cover the expense of doing so.

The fact that an asymmetric risk of mortality remains greater for people living below the poverty line is not erased by ensuring access to health care is not surprising, and it is not an argument that health care for all is a bad idea or a poor investment. It is instead an argument for also working to stop growing the ranks of the poor and to do everything possible to grow a prosperous middle class.

There's almost a hopelessness to this study - where *can* we get bang for the health care buck?

Health promotion is the direction. Can we please talk about health care savings when the FDA is making its decisions? The National Cancer Society says there is no level of processed meats that can be considered safe. OK, "we're broke" - we can't afford the healthcare costs of processed meats any more!!

"Some people will respond to incentives, regardless if you - or even most people - do not. Some people would surely cut back on their sugar intake if they were faced with all of the health costs of diabetes, for example."

Lower income Americans are currently the least likely to have health insurance, and have a generally higher incidence of diabetes than the more affluent and better educated strata of the society that is covered.

Being nagged by a doctor about one's diet and weight, and being educated by the doctor about the potential consequence of contracting (or failing to properly manage) the disease "surely" will reduce (though not eliminate) the incidence of diabetes "for some people" who currently do not have the benefit of such care.

As others have noted, this is a bad headline. It's not that health care/health insurance doesn't keep people healthy, but rather that it isn't the ONLY thing. The part about relative cost/benefit ratios from different types of public health spending is an interesting conversation starter, but I feel like it got lost under the inaccurate post headline.

As a related aside, it should be obvious that Canada is the last place you'd go to study the question of whether access to health care affects health care outcomes - since everyone there has access and you won't have a control group to compare.

"Lower income Americans are currently the least likely to have health insurance, and have a generally higher incidence of diabetes than the more affluent and better educated strata of the society that is covered."

Well sure, but that's a result of intelligence/education as you suggest.

Also, low income Americans don't really have much in the way of assets, so bankruptcy isn't that large of a loss. Your $3,000 bank account is wiped out and you get put on Medicaid.

"Being nagged by a doctor about one's diet and weight, and being educated by the doctor about the potential consequence of contracting (or failing to properly manage) the disease "surely" will reduce (though not eliminate) the incidence of diabetes "for some people" who currently do not have the benefit of such care."

I'll give you that, but consider my thought experiment - eliminate all insurance, for everyone. A serious disease will now bankrupt most people. Which would have a greater effect on people's lifestyle decision making - the prospect of bankruptcy, or two minutes of nagging from a doctor?

"Health care is obviously better for treating illness than no health care"

Not obviously. The health care system is one of the leading causes of death in the United States.

Why is it such a surprise that rich and educated people are healthier and live longer than poor or uneducated people? Where we live, our employment conditions, the stress we face, our race, and our income all contribute to our health and sickness. Health care is but one of many factors. Watch a series called Unnatural Causes: Why Inequality is Making Us Sick (http://www.unnaturalcauses.org/) to get a better picture of the factors that determine our health and sicknesses.

"Well sure, but that's a result of intelligence/education as you suggest."

I never said that persons with low income are less intelligent, justin84.

The fact is that the affluent are better informed on the subject of health, diet, and the mechanisms and consequences of particular diseases. As a result, lower income individuals are the most likely to see a benefit from receiving this information via annual visits to a physician, who can ring an alarm bell about poor lifestyle choices before it is too late.

Arguing that poor people will avoid poor health habits simply out of the fear of the resulting expense of falling ill (disease and death are not a more powerful disincentive than a pile of bills?) is just not borne out by our present experience.

Just found that "123 Get Samples" is promoting a wide variety of major brands by providing free samples. You’ll have to fill in your zip code to see if you can qualify to receive them. You can get all samples from one place. I think it is available for most of the zip codes and it worked for me.

The Canadian health economist Robert Evans explains this by speaking of medical care as our bodies’ repair shops. It’s where we take our bodies when our engines break down.

But why are our engines breaking down so often in the first place? And why are the patterns of engine wear so differentially distributed by class and by race?

Most point the finger at our individual driving habits: our diet, smoking, lack of exercise. All are important, of course. But study after study suggests there’s something at work even more basic than our driving. And that’s the condition of our roads.

Currently, the rich get the best roads: their jobs pay well and give them lots of power and control; they live in neighborhoods with parks and green spaces and supermarkets and fresh foods; they send their children to well-resourced schools. In sum, there’s less stress placed on their engines.

Down the class pyramid, the roads we travel get bumpier, more twisted, more potholes: the anxiety of living from paycheck to paycheck; fear of job loss, foreclosures and downward mobility; speed-up at work; overcrowded and poor schools; worry about our kids’ safety; few supermarkets or farmers’ markets offering fresh fruits and vegetables, only fast food joints or mom-and-pops; or there’s little time to shop and cook after hour-long commutes.

Traveling these unequal roads of life increases the wear and tear on the engines of the less affluent, especially poor people of color, heightening risk for all the chronic diseases - coronary artery disease, stroke, kidney disease, diabetes, asthma, even some cancers. Off to the repair shops we go—if we can afford them.

The result? The rich in the U.S. live on average two years more than the middle class, six years more than the poor. Thanks to the added burden of racism, African Americans, Native Americans and second and third generation Latinos do worse still. Study after study show that class status (income and education), zip code, and race are strong predictors of health even after controlling for diet, smoking or exercise.

Most readers of the Post know that the US has by far the most inequality of all the rich countries. We also have the smallest middle class, the highest poverty rate, and the least social spending per capita. We’re the only rich country not to mandate paid sick leave, paid vacations, universal pre-school and paid maternity leave. Why should we be surprised that citizens of those other countries live longer, healthier lives than we do?

Some sources?

See the WHO Commission on the Social Determinants of Health: http://www.who.int/social_determinants/en/

The Robert Wood Johnson Commission for a Healthier America
www.www.commissiononhealth.org

These and many other studies can be found on the companion web site of the award winning documentary series, “Unnatural Causes: Is Inequality Making Us Sick?”
www.unnaturalcauses.org

Yeah, but prevention is just so crucial over decades. 30-40+ years of not smoking, eating lots of fruits and vegetables, exercising, moderate alcoholic use, keeping your weight down, safe driving, etc., etc. make an enormous difference.

And there's a great deal we can do to increase these things. Taxes on harmful things like soda and cheese burgers can fund subsidies for fruits and vegetables, free gym memberships, education,...

This is one of the more sensible things you've written. There's a next level of analysis that you should also get into.

It's not prima facie wrong to spend 20% of our income on health care, the problem is it's not cost effective and is being employed for the wrong reasons.

So much is being spent for intensive procedures in the last months of life, which many patients don't even want. Much of medicine is actually harmful to us- new drugs, overtreatment, medical errors, etc. Much of it just costs money without doing much at all, and the placebo effect kicks in.

As Robin Hanson says in a summary of many of the studies out there, we could cut medical spending in half and get the same effects.
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/

All of this points to how truly easy it is to extend medical care to all, once you cut back on medical care costs. We have a huge, false association in this country concerning the effectiveness of medicine that's causing us to overspend. If people want to spend too much on health care, it should be their money, not ours. This is we should advocate for plans which give individuals more control over their own health spending budget, and more opportunity to benefit from being personally responsible and spending less, while also offering actual insurance (not just prepaid health care) for the obvious, needed, physical care.

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